Buckle up and get ready for a real ride! Dr Stefanie Green is a Canadian physician with a lot of experience and information to share.
- What is Medical Assistance in Dying in Canada?
- What feelings does Dr Green hear most commonly from patients?
- What is the hardest part of the work she has been doing since 2016?
- What is patient-centered care and why does it matter?
- What are the three things this physician would like you to take away from this conversation?
This talk with Dr Green is my longest BLBD podcast ever – 54 minutes. I was going to cut it in two, but I decided it was just too interesting as one long conversation. Stretch it out if you need to, but I bet you won’t be able to hit pause!
Visit her website at: https://www.stefaniegreen.com/
For more information on Best Life Best Death please visit our website at www.bestlifebestdeath.com
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Diane Hullet: Hi, I am Diane Hullet and welcome to the Best Life Best Death podcast. Today’s guest is really something. Dr. Stephanie Green spent 10 years in general practice and another 12 years working in maternity and newborn care before changing her focus to medical assistance in dying in. She wrote her landmark memoir in 2022 called This is Assisted Dying, A Doctor’s Story of Empowering Patients At the End of Life.
When I asked Stephanie to come on, I was really thrilled by this opportunity to talk to someone who’s been working in the medical aid and dying field for some time and brings a different perspective from the Canadian side of the border. So enjoy our convers. So welcome Dr. Stephanie Green, so happy to
Dr. Stefanie Green: have you.
Thanks for having me. I appreciate the opportunity.
Diane Hullet: I mean, when I read your book last summer, which is called, this is Assisted Dying, A Doctor’s Story of Empowering Patients at the End of Life, I was just blown away because not only are you this intelligent, thoughtful doctor, But you’re an incredible writer, and so I thought the stories in it, the way you brought the whole, all of the issues of medical aid and dying to life through your experience just made for a really compelling
Dr. Stefanie Green: read.
No, I appreciate that. You know, there’s lots of answers about why I wrote the book, but the most honest one for me is that I was finding myself in the most extraordinary circumstances with the most incredible people, and I really wanted to share. With, with people, so they understood what exactly I do and what I hear and what I see and how it feels to do that work.
So that, that was really the
Diane Hullet: goal. Thanks. And, and I, and I think you did so, so beautifully. So, so just back up a little, give us some context. How did you as a doctor get into this work?
Dr. Stefanie Green: So it’s nothing’s linear in life, right? So I have always been really interested in the intersection between medicine, ethics and law, just intellectually.
I find that really stimulating. And for the majority of my career, I’ve, I’ve found that in my work in, in women’s health and maternity care, in newborn care, I prepared women and families for birth and I delivered them and, and helped them through the first chaotic few months and sent them back to their primary care.
I loved that work. I really had a passion for it, but at some point it, it was becoming physically difficult to be doing that work, a 24 hour call shift. I had some need to be at home before my children flew the coop. I was looking for ways I might alter my schedule and look at other interests and. I had always been following the assisted dying debate in Canada, which had been going on for a couple decades.
And we had a court case and a, and a, you know, a law change that was coming. And I was wondering who would do this work. It seemed to me to be the epitome of what I call patient-centered care and that intersection of medicine, ethics and law. And it was really fascinating to me. The more I learned about it, the more I was drawn to it, the more I felt I had the skillset to to, to contribute and.
I, I made that switch when our law changed.
Diane Hullet: Wow. And what year was that?
Dr. Stefanie Green: Well, the law actually came into effect in 2016. The court case known as the Carter case was decided in 2015, and we then had about a year before the law was changed and came into effect.
Diane Hullet: And as you describe in your book, I mean, in some ways it was for personal reasons to make this shift, but then it happened to coincide perfectly with this law, and then you found yourself kind of at the forefront.
You described going to a conference where you met some other Canadian doctors and you realized, You were the ones who were gonna be carrying this forward. Describe a little about that, that group, and just tho those moments in those years of how you got started.
Dr. Stefanie Green: Yeah. I, I was looking to learn about the topic and there was very little in Canada to teach me.
We’d never done this before, so I, I learned of the, the conference you mentioned was an Amsterdam. It happened to be. A World’s Federation of Right to Die. So society’s international conference that they run every two years. And it happened to be in Amsterdam and it happened to be a month before our law was due to change.
So I went and I expected to meet a lot of Canadian clinicians there. And there were very, very few, there were eight of us and six were physicians and, and two were administrators. And we quickly found each other. Yeah. Just were blown away by what we were learning and the people we were meeting and the research that was generated and the, the clinicians with experience who were open to talking with us and we shared our notes and really continued that on After the conference, when we came back, we kept that connection.
And it was so important in those early days when we really felt like we were taking a bit of a blind step into a really new field of healthcare and learn from each other’s firsts. And that support grew into a much larger national organization, which, which, which that small group actually founded and, and has be become a, a cornerstone, a real foundation of, of my support in in this work.
And that’s capp, the Canadian Association of Made Assessors and Providers, I have to say the name because. I have to say how important
Diane Hullet: they’re, say it again cuz that’s so many
Dr. Stefanie Green: words. Yeah, so it’s the, it’s the Canadian Association of Made Assessors and Providers. So we have an acronym within our acronym made being Medical Assistance in Dine, which is what we call the work that we do in
Diane Hullet: Canada.
Wow, that’s so amazing. And so seven years, and you’ve seen so many changes in that time period, I’m guessing. I, is it, is it a fair question to say, tell us about some of those change.
Dr. Stefanie Green: I, I think it’s a fair question. I think what I want to answer first is, what hasn’t changed? I mean, the, the people who come to see me, the reasons they come to see me, these things haven’t really changed.
I, I meet people who, who are reaching out for help who have felt somewhat helpless during their journey, which could be weeks or months or years. They are looking for semblance of control at a time. They feel that they have had none. And a time when they know they’re in general when their life is ending, though not necessarily immediately.
So and, and those people and why they come to see me, the work itself hasn’t changed. What has changed is our understanding of the work. We certainly. Have a much more mature understanding of what the work is and how it should be done and what the law says and how we interpret that clinically. Our law has been amended.
Actually, it was amended in 2021, so five years after the initial legislation, which is federal in Canada. It covers the entire country, all provinces and territories. There was an amendment. Based on that learning and also based on some court challenges. And some of the things we learned were that some measures we had instituted as safeguards were not working, so we removed them.
Other things that were missing, we were able to add. And significantly so. Our original legislation involved some relationship with end of life. Our law said that death needed to be what we call reasonably foreseeable. That was a criteria that our government imposed in the initial law, which was more restrictive than our original Supreme Court decision about this work.
And it was. Challenged immediately, and it took three years and the courts in fact agreed that it was unconstitutional and asked for it to be, you know, demanded that it be removed from the law. So that was a major change in 2021. So a number of changes have happened to the legislation and we’ve continued to try to adopt and adapt to that change.
Diane Hullet: And how many, like in terms of when you started versus your practice now, or, or numbers, you know, generally the first year that it started versus seven years later, how many people are utilizing this law?
Dr. Stefanie Green: So, not surprisingly, the demand has really risen steadily since this became a possibility. I think that’s, True with anything that’s new.
People don’t know about it. In fact. So in the beginning we had trickles of people coming through inquiring about it and we were helping them. That number grew steadily and has continued to grow steadily each year. I think it’s important to contextualize that because some who are opposed to this care have tried to suggest that that is.
Slippery slope of sorts that it’s out of control in some way, but in fact, you need to compare it to other jurisdictions who we’ve learned from. As I’m sure you know, and your listeners know, you know, some form of assisted dine has been legalized in the state of Oregon for over 20 years, Washington state for something similar.
You know that countries of Netherlands, Belgium, Luxembourg, Switzerland, there’s lots of other examples we see in Oregon, which has robust data over decades. We see less than 1% of all annual. Being attributed to assisted dying, but we have to remember that in Oregon and in places in the United States, in order to access this care, you do need to be within what’s considered six months of end of life.
So having a terminal illness, and more importantly patient needs to self-administer the medication, which is In our understanding and what we’ve seen in your experience that is fairly discriminatory against those with physical disabilities or those who’ve become disabled due to their illness, especially those who expect to become disabled due to their illness.
So this is the kind of learnings we’ve had in the place like the Netherlands where their law doesn’t limit administration of medication to be. Administered the clinician themselves can give the medication. In fact, the majority of people request that. And over 95% of all assisted dying in the Netherlands is done by clinicians.
We see about 4% between four and four and a half percent of all annual deaths in the Netherlands are attributed to assisted dying. So a big difference between those two jurisdictions. So where is. Well, we are now six and a half, almost seven years in, and we are of course, somewhere in the middle completely expected.
The last national data we have from 2021 suggests that we are now at 3.3% of all annual deaths being attributable, assisted, dying. Our model is very much similar to the Dutch experience. We allow clinicians to give the care. Over 99% of patients have requested that in Canada, and in fact I think it’s exactly where we would expect to be six years in compared to the, the Dutch experience, which has 20 years.
Do I think we’re going to match the Dutch experience? Yes, I do. Do I think we might surpass it? I don’t know. I, I suspect we might, we have. Very progressive population who has embraced this care and has seen that it can be done rigorously and carefully over the last six years. I continue to see rise.
I con, I expect we’ll continue to see that.
Diane Hullet: Yeah, you, I mean, in your book you described just some incredibly touching scene. You know, it’s one thing to sort of talk about the numbers and then it’s another thing to talk about the individuals for sure. And I, I, you know, I, I know that you can’t like go into a specific story per se, but what has stood out for you?
Dr. Stefanie Green: So much. That is such a loaded
Diane Hullet: question. Well, like I was blown away. I remember the very first patient that you had, you really described so tenderly what his condition was. He was in tremendous pain. He his whole family was in agreement. Everybody was present. And, and you described it as just this. You know, such an offering to him, almost might be the word, and that he was so, so grateful.
And I think he had weeks, maybe months to live. Not, not, I don’t even think it was months, I think it was weeks or days. And you felt like your role in that was to deliver him from terrible pain and it, a degree of suffering that he had been in for some time, an extended period of time. So that like, I mean that the way that you described your relationship with the.
Your relationship to the family and your role in his ending of his life was so touching to me. And that was just one
Dr. Stefanie Green: example. You know, I, I think you’ve actually, you’ve probably touched on exactly what I find the most interesting part that I’ve learned about doing this work and what’s really stands out to me is what I call the paradox of the work.
You know, when someone’s life is ending it is sad. It is always sad. It. Sometimes tragic. It can be incredibly emotional, but assisted dying allows a certain amount of closure. When people know the date and time of their death, they stop worrying about how they’re going to die.
Diane Hullet: And how they’re gonna suffer, right?
How, how they’re going to die and how they’re going to suffer. And we have so much fear of pain at end of life. We do do, I mean,
Dr. Stefanie Green: in in truth, in truth. Our patients do need to be suffering by, by law. They need to be suffering in order to qualify. But our, our, our palliative care colleagues do a really good job controlling.
Physical pain. It’s not the most common reason people come to me for assisted dying. And it, and, and, and international data will, will prove that to be true in all jurisdictions. But like you said, it’s about the patient. But patients do worry about how they’re gonna die and what that’s going to be like and how it’s going to feel and whether it will be painful.
But when people are told that, that they, that they’re eligible for this care, when they plan their death, when they know when it’s gonna happen, they stop worrying about how they’re gonna die and they. Being concerned with how they’re gonna live the rest of their life. They spend their final days focused on how they’re gonna live.
It offers a certain. Of opportunity, of closure and, and so that’s interesting in and of itself. But what I find is when I go to someone’s health to offer this care, it is always sad they are dying. It is always sad, but there have been some extraordinary moments of love and expressions of love and, and for lack of a better word, Beauty that I have witnessed in these moments at the end of life that are so striking to me.
And so that paradox of something being sad and an ending, but also being so achingly beautiful has really struck me and, and it’s in other parts of my work. I. People ask me to be this knowledgeable guide for them through this essentially natural event, just like giving birth, right? When I used to do that work, I was the person who walked in the room to guide them through this event.
But much of the time, especially at end of life, I am witnessing something happening that I have not orchestrated at all that that collaboration of family and friends around this person the way they are saying goodbye. I’m often awestruck at what is unfolding in front of me. I’m not the guide to that.
They are showing me how this can be done. So am I the guide or am I the witness? Paradox. Right? And, and, and you know, is it, is it an ending and a sadness? It is. But beautiful paradox. It just, it strikes me over and over again in this work that, that you, that I see that kind of juxtaposition. That’s,
Diane Hullet: that’s so well put.
I, I’m, I’m thinking of two things. One, I interviewed a wonderful end of life practitioner named Jade AdGate. She said that at her best, she was really just a guide and a witness supporting the caregivers and the family members and friends. For them to make the connection with the loved one who was dying.
It really, it really isn’t her. It’s her supporting that container, if you will, of helping the family to help the person die. And so there is something about that witness, that objective witness coming in who doesn’t know the family and yet is there at the end that can help create this, this alchemical kind of magic sometimes.
And. And in your case, it’s supporting medically as well. It’s so huge.
Dr. Stefanie Green: I, I, I have to say, it’s one of the things that I also recognized from this work kind of early on, which I didn’t expect. My, my work in maternity care, I really believe prepared me so well for this work and, and growing on what you just said.
You know when you go in to do a delivery, like I said, you’re supposed to be this guide, but I’m also acutely aware of the fact that I’m not the most important person in the room, right? I mean, what you’re saying, the dad, the mom and baby, they’re the most important people. I’m there to facilitate that for them and for their family.
And the same can be said at at end of life. I am certainly not the most important person in the room. I’m there to contribute and to. But at some point, it’s my role to gracefully withdraw from that moment and just be a respectful witness or even leave the space and allow them that bereavement. It’s such an important.
Choreography that happens and I’m so grateful that I had over 20 years in maternity care because I think it really prepared me well for that type of role. I was able to take that skillset and, and just use it directly at end of life care, and it’s been so, so helpful for
Diane Hullet: me. So beautiful. I mean, in your book, really kind of somewhat towards the end is where I remember it being, you talk about struggling to find the right word for these procedures, you know, and then you realize that it’s the same word.
That you used around birth. It’s delivery. It’s a delivery. I just, I mean, I think that was the point of the book that I cried, cuz I just thought that was so incredible that you could feel that connection between the two and realized it’s the same word.
Dr. Stefanie Green: It’s the, it’s that transition, right? That transition into life, that transition out of life.
That, that delivery in, that delivery out of suffering. It’s, it, it was so, it just really clicked for me. It really fit. At some point, I really recognized, I, I, I felt like that’s, that’s it. That’s the word. People were constantly struggling. They continued to struggle with how to talk about this work. You know, journalists friends, colleagues at work, people are scared to say the words.
They’re not really sure what the polite word. Be, you know, when you go to do that that thing you do, they’re saying like, they’re not sure. And so I thought, well, I’m, I’m gonna call it a delivery. I tell my husbands, I’ve got a delivery this morning and he knows I’m going to to assist somebody. And it just, just
Diane Hullet: feels right.
Somehow procedure is a little clinical or yeah. I love that. It’s just, it’s direct and also beautiful. Yeah. I was also thinking from what you said in the p earlier moment, there was, there’s a Canadian death doula named Sarah Kerr, k e r r and I, I just love her work and I recently saw some work she did about pet death.
Mm-hmm. And in the pet. Video training, she talked about how we often get entangled and we think because it’s sad, it’s bad, or because it’s hard, it’s bad, right? And, and she said, you know, death is always sad. It’s often hard, it’s never bad. And I just found that super moving.
Dr. Stefanie Green: Well, death is part of life. I mean, it sounds cliche to say that, but we all know that to some extent.
We all know that death is the last chapter of life. And I think if we could recognize it as such and almost embrace it as such, we could talk about it more. We could prepare for it better, and, and then, you know, if we can prepare for it better, we’re going to live better. It’s, you know, preparing for death allows us to live more meaningful lives.
So it’s really. Something we should be talking about more. And that’s, that’s the other reason I, I wrote my book. I wanna contribute to that conversation. I wanna, I want to, I want people to talk about death and dying. We’re so, We’re so resistant to doing so. I want to talk about death and Dine as a whole.
I wanna talk about end of life options in general. Shed a light on them. And yes, I want to talk about assisted dine in particular. I, I think I have a, a certain perspective as a, as a practitioner of assisted dine. I think I have a unique and, and important contribution to that conversation, but it’s not so important to me that you agree or don’t agree with assisted dying.
What I want is to stimulate that conversation and most important, That conversation within ourselves, even if it’s not with someone else. I want someone to take a moment and think, who would I want standing next to me when I’m dying? Whose hand would I wanna be holding? What do I wanna be remembered for?
What brings me joy and meaning in my life? Because those are the questions that lead to the answers to those other questions about death and what we want. And as you see very quickly, You, you, you understand maybe without realizing that assisted death is less about death than it is about how we wish to live our lives, and that’s a conversation I think we can all benefit from so valuable.
If I can stimulate that internal honest conversation within yourself, wow, then I think that’s great. That’s really what I wanna see happen.
Diane Hullet: That’s really, really amazing. Because it is an internal conversation within ourselves, and we kind of make it about laws and other people and what the, what, what the world says we can and can’t do.
And I, I think we wanna make it simpler than it is. And maybe it’s another paradox because maybe it is kind of simple and it comes down to your own heart space and what is right for you.
Dr. Stefanie Green: Yeah, exactly. It’s it’s such a personal question and it’s, it’s so unique to each individual. Yeah, and that’s why patient-centered care is so important in this field.
Say more about that. Patient-centered care is exactly what it sounds like. Patient-centered care is when we focus. On what the patient believes is the most important thing for them. It’s our job as clinicians, as educators, as the people around to offer information, to offer guidance, to offer whatever it is that the patient needs to help make their decision for themselves.
It’s, you know, the days of paternalism and medicine. I’d like to think. Are behind us. It’s not for me to tell a patient what’s best for them, it’s for me to inform them what those options are. Whether it’s three different forms of chemotherapy. One is aggressive, one is less, so, one is successful, one is less.
So if I can explain that information and allow the patient to, to consider that in within their own set of values, within their own community, within their own family, within their own life experience, they are the expert on the. I am not an expert on them. They are. So if I can inform that decision for them, I’ve done my role.
That’s what patient-centered care is. It’s a core pillar of, of family medicine as I was trained, and I like to think that I practice that throughout my career. Assisted dying is really the epitome of all that, and it’s really no different than any other form of medical care in that way. I still see my role as the same.
I still see the patient as autonomous and capable to make their own decision. With an expert knowledge of themselves and who they are and their value system and their community and their religion and their culture and their ethnic background and their life experiences. So I wanna, I wanna offer that to them.
I wanna facilitate their best decision for themselves.
Diane Hullet: How do you think, like, why do you think we got away from that? Or did, did we get away from that?
Dr. Stefanie Green: Or did we get away from that? That’s a good question. I think we come far from it. I think, you know, you have to look back a hundred years ago. Most people in North America died at home.
Right. It was much more familiar to us. Children saw it it was less taboo.
Diane Hullet: They also, they died of diarrhea. They died of flu. They died of pneumonia. Right. They died of things that we now prevent. Yeah. I’m
Dr. Stefanie Green: not suggesting it was necessarily better or worse, but I am suggesting that modern medicine has saved countless lives and.
Done tremendous things and I am grateful for them and will forever be. I’m also suggesting that modern medicine took death and dying out of the home and out of the community and placed it in the hospital where it did really good things. But as we all know, It has made us removed and unfamiliar with the topic in general.
And so I think there was a stage then where medicine was exalted on a pillar as all knowing that we should, you know, listen to what the doctor said. And there is some place for people with expertise. I’m not suggesting we don’t listen to those with expertise. I’m a big fan of expertise. I think somewhere in the way there, we, we lost the voice of the patient and, and their expertise on themselves.
And now I see that return to what I was talking about where we hopefully have more of a two-way conversation. It’s not one person telling the other. And, and, and, and I think that’s been a positive shift in, in healthcare.
Diane Hullet: I think a really positive shift. How, how do people you know, you’re the average person and you get a diagnosis and you’re concerned.
H how do you take that back? How do you make it a patient-centered experience? Oh, that’s
Dr. Stefanie Green: a great question. I guess it’s, I suppose it’s different for everyone. You, I think we need to allow patients to, Absorb and digest something they’re less familiar with. You might be a clinician who is used to talking about illness or disease specific as it may be.
You might have experienced telling someone they have cancer or, or something else, but for that patient, This is a once in a lifetime moment. You know, they can’t, they can’t take it all in at once. They can’t understand it all at once. We need to give time and space to digest that. We need to give supports around them so they can ask questions as they occur to them.
We need to have serial meetings. We need to allow them a venue. To explore what this means for them. We need to do all of that. That’s how we can make, make it a patient-centric experience so we can hear them. We shouldn’t just impose the three things we wanna tell them. We need to make sure they can actually hear us when we’re talking to them, and that means giving time and space for their reaction.
Diane Hullet: Right, and I don’t know about the Canadian system, but in the US system right now, there’s not a lot of time. Like what we’re talking about takes time. It takes a conversation, it takes some space to explore those options and when the doctor feels crunched by time and what they need to get to next, I, I mean, I just think doctors are extraordinary when they’re able to.
Very quickly shift gears to be with the patient they’re with and be a hundred percent with that patient for 10 or 15 or 20 or 30 minutes, and then go do it again with somebody else. It, it takes tremendous focus. It takes
Dr. Stefanie Green: tremendous skill to be honest, and I think one of the skills of a, of a good doctor is to meet a patient where they’re at.
So you need to, one of the greatest skills as a clinician is to close your mouth and listen for a moment and to hear the emotion and to hear. The reaction and to hear the questions or to hear the silence. And to, and to meet the patient wherever they’re at in that conversation. And if you can do that well enough, you can do that in 20 or 30 minutes and you can, you can at least establish a, what we call a therapeutic relationship.
Something where they trust you and you trust them and, and you can explore that
Diane Hullet: further. I’m sure you know the book being Mortal, which I, I talk about here and there cuz I love it so much. Do you know that one?
Dr. Stefanie Green: And I do. It’s been a while since I.
Diane Hullet: One of the passages in that are chapters enough that I love is where he talks about this small town in the northern Midwest and they, the doctors basically all knew each other.
So they got together and they decided, you know, let’s ask patients what they want at the end of life. So they kind of developed a questionnaire and they started simply anytime someone came in the office when they were over the age of like, I don’t know, 60 or whatever, they decided, they handed them this questionnaire.
And over time it had an impact on the entire town and the healthcare system of that area. Because the questions were being asked, the conversations were being had, but maybe even more importantly, the patients, the people were thinking about these things and as we kind of said at the beginning, like this idea of how do we spark these conversations within ourselves to think about what we want and what our values are, knowing that everyone is so individualized.
So I thought that was such a great example. Bringing this forward more than once over time, so that it could kind of cook. You know, it’s like a slow simmer. These conversations don’t do well at a hot boil. You know, they do better as a slow
Dr. Stefanie Green: simmer. They don’t, and it’s, it’s interesting that, you know, that’s a such an amazing initiative.
And I think that one of the things that it reminds me of what I see is, It opens the door to the conversation. I think I actually believe patients wanna have those frank and honest conversations somewhat in advance, but especially near end of life. And I am still troubled to find many, many patients walk through my door, never really having had an open and honest conversation about what their true options are at end of life.
And permission to talk freely about what’s important to them. That is. You know, I, I think the idea of having that questionnaire and, and using it in patients in general as a rule overall for everyone, yes, allows them to digest, but also opens a door for permission to have the conversation. Once you know that you can sit down and speak those words to the clinician, it’s amazing what comes out.
It’s it’s really amazing the, the two emotions I am constantly exposed to in this work. Gratitude and relief. A relief for the ability to have this conversation. Thank you so much and gratitude for the conversation and eventually the care. But those are the two emotions I see the most coming from patients and they’re really, really grateful.
Diane Hullet: interesting cuz you know, I teach classes that kind of encourage people to look at these questions and end of life. And I just read the greatest comment, just a little short comment from someone from a class and she said, In one class, I went from being scared and apprehensive to being curious and feeling like I could be productive and learn amazing, you know, amazing.
And I thought, well that, and all that was, was one little simple class with a small group on Zoom talking about some of this stuff. And she completely was able to shift her perspective and attitude. And that’s I think what, what I’m trying to do in my work. And, and you’ve got the, the kind of the other. I don’t know.
I just think you’ve got such an interesting insight into people’s lives and as you said, how incredible, like I would not have guessed that you would say the emotion you, you come in contact with the most is relief and gratitude.
Dr. Stefanie Green: Oh, overwhelmingly so. Especially when I, especially when I have the opportunity to sit with someone having been through the rigorous process.
I mean, we’re not outlining everything that needs to happen. It’s quite a rigorous process. When I can sit in front of someone and I say, You are now eligible for this care. Doesn’t mean you’re gonna have it. Doesn’t mean you need to, but you can. You are now empowered to make this decision if it’s what you feel you need.
There is a transformation that happens almost every time, right in front of my eyes, right? I see. I see their shoulders drop. I see their head kind of start to nod. Imperceptibly, usually a bit of a smirk or a smile on their face, followed almost immediately by an expression of gratitude. People are so grateful for the possibility.
Of this care that is undoubtedly objectively therapeutic in and of itself. I am convinced of that. I’m, I’m astounded by that. I did not expect that. And I am, I’m, I’m constantly surprised by that, that I, that I keep seeing it. Absolutely therapeutic. Well,
Diane Hullet: you know, another piece that really stuck out for me in, in your book was an example of a person that you met with who was not eligible.
Mm-hmm. And I believe that person was not eligible because they had a, some kind of dementia and they were beyond the point of being able to choose this and. You were kind of brokenhearted. You were like, ah, this would’ve been a really good option for this person three, six months ago, but now they don’t qualify.
Can you speak to that at all?
Dr. Stefanie Green: Yeah. Telling people that they’re not eligible for this care is, is probably the hardest thing I do. I you know, people come to me usually quite desperate and. And suffering by definition. And a lot of what I do is is validate their experience. I, I hear it. I see it. I, I can, you know, I, I tell them that I hear it and see it, but I am not an activist who’s looking to change the, the laws of the world That is not me.
I’m a clinician looking to work within the boundaries of the law that my country sets, and I will always work within it. And there are some people I, I feel badly for. I understand their experience. I believe they’re suffering, but I cannot help. And in those situations I, I need to explain that to them and that is not a conversation they wanna hear.
And they are often quite disillusioned, you know, when they leave my office and I, I worry about what will happen next when they leave my office. That is a real concern.
Diane Hullet: Well, and there’ve been a huge, you know, huge number of articles and so forth coming out lately too. There are critics of this work, of course.
And how do you respond to those who say some version of, you know, this is not right.
Dr. Stefanie Green: Well, there, there’s, there’s two answers to that question. So I, I, I would actually ask. I would actually ask exactly what is it that’s not right. I mean, I do think a clinician’s role of all the things we say in our med school interviews, a clinician’s role essentially is to help people.
I mean, you know, there’s that expression, which I just love that we. Cure sometimes. We care often and we comfort always. I mean, it’s nice when we can cut the booboo out and make it better, but that’s not the bulk of what doctors do. What we do is we comfort always, we prov, we provide help. And so I, I, again, I question what is it that’s not right.
I shouldn’t. That I shouldn’t be there to help someone at the end of their life in a time of need. That that doesn’t seem not right to me, is what’s not right. That the, that the patient gets to say and have dominion over their life and their decisions about their care, I mean over their bodies, over their decisions, over their end of life decisions.
That doesn’t seem not right to me. I mean, what exactly is it that’s not right. So I I, I throw that back when someone says it’s not right. Really? What, what exactly is not right? You brought up the issue though of some of the media sensations, some of the stories we’ve seen. There’s a conflation of several issues happening.
In my opinion. I think there are really legitimate issues and concerns that need to be raised, and we should. Dismiss them. I, I think that they’re not all necessarily about assisted dying. We certainly have, I would say, inadequacies in some of the social resources we need to have in our communities.
We do not have adequate mental health resources in our community. We do not have adequate disability supports in our community. We do not have adequate housing supports and basic income supports. Those are legitimate complaints about our social fabric. And I am the first to say we gotta do better at every level, municipal, provincial, federal.
And I invite anyone who thinks So to stand next to me, to, to, to share the bullhorn. I have found that some of those who are opposed to made are using that as leverage to oppose made. And I think those are different issues. So when people step forward and tell stories to the media, I’ve lost my housing, I’m gonna apply for maid, I don’t wanna live homeless.
Everybody has the right to see an assessor and be assessed for MAID and to. Talk about why they believe this is the best choice for them. Nowhere in our law does lack of housing qualify someone for assisted dying. Nowhere in our law does poverty make someone eligible for this care. Do those things contribute to their suffering, which contributes to their possible eligibility for made?
Sure. I’m not denying that, but just because someone says they’re gonna apply for me doesn’t mean they’re going to qualify or receive it. And so I, I caution people to know the whole stories and the whole backgrounds. That said, I think there is some element of, I don’t know what we call it. We are still learning what to do in situations when a patient arrives in my office and has a.
Vulnerability is potentially marginalized in society, has issues systemically working against them and has for many decades, and they come to me saying, I’m done. I can’t take this anymore. I would rather have an assisted death and resources that I would like to offer them aren’t necessarily available.
So what do I do as a clinician when a patient comes and by the letter of the law seems to meet criteria? But it seems to be mostly because the resources I’d like to offer them aren’t available either at all or in a timely manner. I might have someone with chronic pain come see me and say, I can’t take this anymore.
And I’d say, well, there’s a pain specialist in the city next door. I would like you to see. They’re really great. And they might even say they’re willing, but it might be a three and a half year wait to see them. And that might not be acceptable to the patient. And our law doesn’t compel anyone to accept treatment that they’re, you know, unwilling to accept.
That would be you. Just unacceptable in our law. So when they say to me, I’m not willing to wait three and a half years, I would rather end my life. I start to not feel right about that. That doesn’t seem right to me. The law says they’re eligible technically, but I am conflicted about that. That gives me moral distress.
So we need to talk about those situations. We need to consider what to do in those situations. How can we do better? I can’t fix society’s inequities and. At the same time, I don’t think individuals should be held hostage to society’s failings at some point. I believe in patient-centered care. If the patient tells me that they have tried everything that’s reasonable and available to them.
In diameter and a circumference of space and geography that is reasonable to them. And they, they know that there’s a three and a half year wait, but they’re unwilling to do that because of their particular situation and life experience. Who am I, who is our government to say, Nope, you need to continue suffering for three and a half years, and if that doesn’t work, then we’ll offer you potentially assisted dine or not.
But I, I think there’s there’s a problem with that just as much. So these are difficult situations.
Diane Hullet: These are huge issues. These are huge, huge issues. And I go back to what you said about, you know, your interest in medicine, ethics and law. Like that’s really what drew you to this. Is has that always been true for you?
Dr. Stefanie Green: Hmm. I, I think so. I I don’t know where it came from to be honest. I think I’ve just been interested in the complicated things in life. Put a strong sense of, it sounds a little arrogant with, of justice, of what’s right and what’s wrong and what I think is right and wrong and how, I don’t know always what’s right and wrong and the curiosity that comes from odd philosophical situations.
They’re like riddles almost. I’m so fascinated in those and what others think is right and wrong and, and then trying to decide what I think is right and wrong based on that information. And it’s always evolving, right? It’s just, for me, it’s very, very, Very, very interesting and, and just captures my, my interest.
Diane Hullet: Well, it’s really, it’s this again, Jade AdGate who I talked to recently, she, she said, you know, death is so perplexing, and I thought it was such a great word because, you know, it’s, it’s, it’s perplexing to humans and to kind of navigate these, these new options for people in all different countries with all different laws and the ethics of it and the personal choice of it.
It’s really an interesting time.
Dr. Stefanie Green: It’s, it really, it really is. That’s the other thing people talk about. They talk about, you know, those who are opposed to this work often talk about, you know, how can the, how can clinician be in that position? That’s not your job to do. You know, I, I believe it’s my job to help, but it’s really, well, maybe I’ve said this, it’s, it’s really about facilitating a person’s final wish.
I, I don’t believe that I’m ending their life so much as the medical condition that’s causing their decline and their suffering. That’s what’s harming them. That condition is what? Causing them to reach out and, and, and want this care. My job is to facilitate their final wish. And I don’t think that’s semantics.
I think that’s the reality.
Diane Hullet: Wow. Yeah. This is, this is a personal question, which maybe you don’t want to answer, but it popped in my head that my kids sometimes who are kind of middle, late teenagers, they’re sometimes like, oh mom, really? Another conference on end of life. Or, you know, really you had to go up and tell my friends mom that you have a podcast about death.
Like, really? Mom, do. Do your do your children have some kind of. Pride in all that you do? Or are they kind of like, oh, here goes mom again?
Dr. Stefanie Green: Well, my kids grew up at a time so minor. My kids are in their twenties at this point. I don’t know how they got there, but but they grew up while I was doing maternity care in a, in a relatively small city of, you know, less than 300,000 people.
So for them it was, we would go to the mall or the grocery store or just walk in the neighborhood and we could almost never not run into someone who knew me from that work. Oh, Dr. Green, you delivered my three children. You know, that kind of thing. And it’s so lovely for me to reconnect with people and I always stop and I love that.
But I think they got a little, mom, come on, I’m not a person. We just gotta go get those sneakers. You know? So it was more of that, to be honest, when I made the shift, they were already in high school or just about to leave the home. And so they had a, a different appreciation for my shift. And I’m, I’m very happy to say my children are both incredibly supportive of my work.
They understand what I do, and, and I, I daresay a little bit proud of, of my.
Diane Hullet: That’s, that’s fabulous. That’s wonderful to have that kind of like. Sense of personal support for such interesting work because you really are at a, you know, I think the work you do is at such a personal level with people and then it’s at such an advocacy level at your city and province and national level.
And then, you know, I’m assuming you’re speaking at international conferences on this kind of work. So the name Dr. Stephanie Green is definitely out there in the world, in the medical, medically assisted, Wait, what do you call in Canada? Medical, medical
Dr. Stefanie Green: assistance and dying. We call it aid, medical
Diane Hullet: assistance and dying.
And here we call it medical aid and dying is what I’m mostly hearing. But I think these terms keep kind of you know, shifting and, and moving in different ways as. As the field develops.
Dr. Stefanie Green: Well, I, I think words are important and we can get into that another time if you want, but no, no. Go. I think words are important.
Yeah. No, I, I think the words we use are really important and they, they shape the conversation and there’s lots of conversations, lots of confusion around the terms that are used. I mean, people will talk about assisted suicide, they’ll talk about euthanasia, they’ll talk about medical assistants and dying.
They’ll talk about physician assistant and dying so lot. You know, voluntary assisted dying. Different jurisdictions have different terms, but it’s important to know really what they mean. I think assisted suicide is the term that’s still commonly used in, in the United States, much more so than in other places, and, and really refers to a time when a, when a patient self administers a medication that has been prescribed by a c.
But that the patient self administers it and it causes their death. That’s kind of the, the, the ultimate understanding of what assisted suicide is, and that’s where the term physician assisted dying or physician assisted suicide came from. Euthanasia is a term that technically, if you go back, what it means is a good death.
It comes from the Greek. But in the modern world it means a time when a clinician administers the medication that causes the end of life. So the only difference between them assisted suicide and euthanasia is in who administers the medication. Euthanasia, unfortunately, of course, was used euphemistically.
By the perpetrators of horrors during the Second World War. And so those who were opposed to assisted dine will often use that term on purpose to cloud that issue or to insinuate something. And in fact, those who were opposed will also use the term assisted suicide because for many, many decades the word suicide was associated with negativity and in fact, crime at some point, it was a crime to commit suicide.
So the use of those terms can be pejorative on. And many jurisdictions have purposely avoided those terms for those reasons. And so, so Canada, of course, uses medical assistance in dying to, as an umbrella term that includes both self-administered care and clinician administered care because we actually allow both in our country.
And so it’s more descriptive and more all encompassing. So I think it, I, I do think terminology is very important to understand where it comes from historically and what is used today and why. And, and yeah, words are important. I
Diane Hullet: think it matters a lot, and I think this, this, say a little bit more about physician I can’t remember the word you just used, you know, when the physician does it versus the person does it,
Dr. Stefanie Green: the clinician administered care.
Diane Hullet: That’s it. Yeah. Say a little bit more about clinician administered versus the person having to drink something and, and that tension between people who aren’t able to administer to themselves.
Dr. Stefanie Green: Right. So, So in some jurisdictions, in, in all of the United States, and this is not meant as a dig at what happens in the us I, I, I don’t mean it that way, but it is required by all the various state laws that assisted dying needs to be self-administered in the US And I, I use the term assisted dying as the generic term for all the things that we’re talking about.
And. What’s interesting is that all of those jurisdictions in the US also require a prognosis of six months or less. But what happens is that as people declined through their illness, they become less and less capable and able to function. And so the classic case that many people will turn to when talking about why assisted dying might need to be legalized or why they encourage it to be considered.
We often talk about cases of people. With als am Myotrophic Lateral Sclerosis, or what commonly called Lou Gehrig’s disease, a devastating neurologic condition that’s progressive and ultimately leaves the majority of people with full capacity in their mind and their body just continually gets worse and worse, and they lose abilities to stand and eat and breathe and and, and do anything.
And ultimately, most will die from respiratory distress or failure or complication. And what’s interesting is that although most people agree these. Patients who could be helped by this care. And of course, this is exactly the kind of patient we would want to help with this care because it’s such a cruel disease by the time there, within six months of the end of their life, most patients with ALS have certainly lost the ability to swallow and, and, and the ability to push a plunger to, you know, even defeat a feeding tube or even in some states, a rectal tube.
So you. You’ve developed a law that’s meant to help patients like this, and you’ve then cut them out of the possibility of ever receiving it simply because they can’t self-administer it themselves. And when we see that other jurisdictions learn from that, they see that, they think, oh, that must not be what was intended.
So Australia, of course, has laws that says, yes, you need to self-administer the care unless you are someone who’s physically incapable of doing so, in which case the clinician may offer to do so and it’s not a crime to do. So that is. That is experience and that’s what’s happened else. We also had the benefit of watching what was happening in the United States and in other countries and saw the same thing.
So we, we allow both options. And what I find interesting is that when I present both options to my patients as objectively as I can, and I, and I have to admit, we have access to I, I would, I would just frankly say better drugs for the oral administration. We have. To secret Bartol, which is not available in the United States.
It’s one drug and it’s effective. You know, when I offer both of those 99.9% of my patients choose clinician administered care. They like the idea that it’s controlled by the physician. They like the expertise in the room. They like to know that it will be a hundred percent effective if we have the technical skill to put an IV in.
They like the fact that there’s very. You know complication rate. And so I, I understand that, and it allows patients with neurologic problems like ALS or anybody to receive the same care without being limited by that self-imposed nature. So I, I do think that learning has been exceptionally important in Canada.
Diane Hullet: Australia. Yeah, and Australia. I, I love that. I’ll be so interested. I mean, I don’t love it. It’s so complex, but I, I like hearing about it and I’m curious about how that will play out over time in the US and in in other countries. I, I just had a friend reach out to me this morning who’s had a best friend diagnosed with a l s and she said, I’ve gotta talk, I’ve gotta talk to you.
And I also just saw this weekend, the new documentary film called Jack has a Plan.
Dr. Stefanie Green: Oh yes. I haven’t seen it yet.
Diane Hullet: Yeah, it was, it was really something and a, a beautiful arc of a story about a man in San Francisco who has a brain tumor that actually comes back over time and, and. What I loved about it. I’m gonna, this is a slight spoiler alert, but what I loved about it is, you know, the whole time you hear the title, Jack has a plan and you think Jack has a plan to end his life.
Well, yes. But right at the very end, the wife is interviewed and she, she says, you know, all along Jack had a plan to be surrounded by family and. And he was Oh, right. And like it just puts this beautiful layer on it that yes, he had a plan to use medical aid and dying, but he, his plan was to be himself until the end and not his plan was to
Dr. Stefanie Green: live as much as he could.
Right. I mean that’s, that’s the thing. When you have the plan for end of life, it allows you to plan how to.
Diane Hullet: Yes. And so rather than going into a period where he wasn’t capable of living and being who he knew himself to be, he his, his life ends before that. But, but there, the one thing I felt in the movie that they didn’t, they didn’t quite say it with, the kind of clarity I would’ve liked is, is they didn’t quite say he’s gotta do this before.
He is not capable of doing it. Right. Right. Because it had to be self-administered. And so there’s just Exactly, there’s so much to. I have one more question. Sure. You know, I guess what I would say at the biggest level is like, what, what would you like listeners to take away from a conversation like this?
Dr. Stefanie Green: I’m gonna pause before I answer that question cuz there’s, there’s, there’s several things. I think what I’d like patients to take away from a conversation like this, I think. There’s probably three things I’d like them to take away. One is what I’ve spoken about earlier. I’d like people to consider discussions about death and dying to consider what’s meaningful to them in their life, what brings them joy, what brings them meaning, what’s important in their life so that they can, they can know that and they can live, that they can manifest that, so that when they get to the end of their.
They can feel like they’ve given that justice. I’ll say, I think the conversations around death and dying lead to those kinds of internal conversations, and I think if I can contribute to that conversation happening, then that’s wonderful. I think the second thing that I would. Really like people to take away from a conversation like this is the notion that assisted dying is less about death than it is about how we wish to live.
Because I, I have found that to be true in my work, and it’s something, it’s an idea I’d like to share. I think it’s really important and on a very superficial level. You know, what do I want people to know about assisted dying? I actually wrote something once and I I, and it was for a Canadian publication, and I said, I, I want people to know that where I work and live assisted dying is legal.
Available free of charge doesn’t affect your life insurance benefits, and although emotionally charged and often sad, it can also paradoxically be. Comfortable and at times remarkably beautiful. I want people to understand it is but one tool, one option at the end of life. And while uncommonly chosen, it can be delivered safely and is currently done so within a rigorous healthcare system that’s regulated and is, it is offered by compassionate, careful, and caring healthcare provider.
Diane Hullet: Thank you so much, Dr. Stephanie Green. I don’t think you could have laid it out more fully. Those three things are just fabulous. S. Yeah, there’s a real limit. Stephanie, I just appreciate your time so much and your expertise. I’m just, I’m just tickled. I mean, I, I first heard about your work last summer, bought your book and, and thought, wow, someday maybe I’ll ask her to be on the podcast.
And here we are.
Dr. Stefanie Green: Pleasure. A real pleasure to be here. I really appreciate the opportunity. Always great to talk to people.
Diane Hullet: You’ve been listening to the Best Life Best Death podcast. I’m Diane Hullett. You can find out more about the work I do at Best Life. Best death.com and Dr. Green. Where can people find out about your work and your book?
Dr. Stefanie Green: Best way is probably to go to stephanie green.com, but Stephanie’s with an f like Frank in the middle, otherwise you’ll go somewhere else. Wonderful.
Diane Hullet: And her book is called, this is Assisted Dying, A Doctor’s Story of Empowering Patients at the End of Life. Thanks so much for your
Dr. Stefanie Green: time. Thanks so much for your curiosity.